Chapter 5 - Engaging the Family Into Treatment
Previous chapters have described the basic concepts of BSFT, how to
assess and diagnose maladaptive interactions and their relationship to
symptoms, and the intervention strategies characteristic of this
approach. These concepts also are the building blocks for the techniques
that are used to engage resistant families into counseling.
This chapter defines, in systems terms, the nature of the problem of
resistance to treatment and redefines the nature of BSFT joining,
diagnosing, and restructuring interventions in ways that take into
account those patterns of interaction that prevent families from
entering treatment.
The Problem
Regardless of their professional orientation and where or how they
practice, all counselors have had the disappointing and frustrating
experience of encountering "resistance to counseling" in the form of
missed or cancelled first appointments. For BSFT counselors, this
becomes an even more common and complex issue because more
than one individual needs to be engaged to come to treatment.
Unfortunately, some counselors handle engagement problems by
accepting the resistance of some family members. In effect, the counselor
agrees with the family's assessment that only one member is
sick and needs treatment. Consequently, the initially well-intentioned
counselor agrees to see only one or two family members for treatment.
This usually results in the adolescent and an overburdened
mother following through with counseling visits. Therefore, the counselor
has been co-opted into the family's dysfunctional process.
Not only has the counselor "bought" the family's definition of the
problem, but he or she also has accepted the family's ideas about
who is the identified patient. When the counselor agrees to see only
one or two family members, instead of challenging the maladaptive
family interaction patterns that kept the other members away, he or
she is reinforcing those family patterns. In the example in which a
mother and son are allied against the father, if the counselor accepts the mother and son into counseling, he or she is reinforcing the
father figure's disengagement.
At a more complex level, there are serious clinical implications for
the counselor who accepts the family's version of the problem. In
doing this, the counselor surrenders his or her position as the expert
and leader. If the counselor agrees with the family's assessment of
"who's got the problem," the family will perceive his or her expertise
and ability to understand the issues as no greater than its own. The
counselor's credibility as a helper and the family's perception of his or
her competence will be at stake. Some family members may perceive
the counselor as unable to challenge the status quo in the family
because, in fact, he or she has failed to achieve the first and defining
reframe of the problem.
When the counselor agrees to see only part of the family, he or she
may have surrendered his or her authority too early and may be
unable to direct change and to move freely from one family member
to another. Thus, by beginning counseling with only part of the family,
excluded family members may see the counselor as being in a
coalition with the family members who originally participated in
therapy. Therefore, the family members who didn't attend the initial
sessions may never come to trust the counselor. This means that the
counselor will not be able to observe the system as a whole as it
usually operates at home because the family members who were not
involved in therapy from the beginning will not trust the counselor
sufficiently to behave as they would at home. The counselor, then,
will be working with the family knowing only one aspect of how the
family typically interacts.
Some counselors respond to the resistance of some family members
to attend counseling by agreeing to see only those who wish to
come. Other family counselors have resolved the dilemma of what
to do when only some family members want to go to counseling by
taking a more alienated stance saying: "There are too many motivated
families waiting for help; the resistant families will call back when
they finally feel the need; there is no need to get involved in a power
struggle." The reality is that these resistant families will most likely
never come to counseling by themselves. Ironically, the families who
most need counseling are those families whose patterns and habits
interfere with their ability to get help for themselves.
Dealing With Resistance to Engagement
When some family members do not want to participate in treatment,
has called the counselor asking for help, that parent is not powerful
enough to bring the adolescent into counseling. If the counselor
wants the family to be in counseling, he or she will have to recognize that the youth (or a noncooperative parent figure) is the most powerful
person in the family. Once the reason the family is not in treatment
is understood, the counselor can draw upon the concept of tracking
(as defined in Chapter 4) to find a way to reach this powerful person
directly and negotiate a treatment contract to which the person will
agree.
Counselors should not become discouraged at this stage. Their mission
now is to identify the obstacles the family faces and help it surmount
them. It is essential to keep in mind that a family seeks counseling
because it is unable to overcome an obstacle without help. Failed
tasks, such as not getting the family to come in for treatment, tend to
be a great source of new and important information regarding the
reasons why a family cannot do what is best for them. The most
important question in counseling is, "What has happened that will
not allow some families to do what may be best for them?"
In trying to engage the family in treatment, the counselor should
apply the concept of repetitive patterns of maladaptive interaction,
which give rise to and maintain symptoms, to the problem of resistance
to entering treatment. The very same principles that apply to
understanding family functioning and treatment also apply to understanding
and treating the family's resistance to entering counseling.
When the family wishes to get rid of the youth's drug abuse symptom
by seeking professional help, the same interactive patterns that
prevented it from getting rid of the adolescent's symptom also prevent
the family from getting help. The term "resistance" is used to refer to
the maladaptive interactive patterns that keep families from entering
treatment. From a family-systems perspective, resistance is nothing
more than the family's display of its inability to adapt effectively to
the situation at hand and to collaborate with one another to seek
help. Thus, the key to eliminating the resistance to counseling lies
within the family's patterns of interaction; overcome the resistance in
the interactional patterns and the family will come to counseling.
In working to overcome resistant patterns of family interaction, tasks
play a particularly vital role because they are the only BSFT intervention
used outside the therapy session. For this reason, tasks are
particularly well-suited for use during the engagement period, when
crucial aspects of the family's work in overcoming resistance to counseling
need to take place outside the office--obviously--because the
family has not yet come in.
The central task around which engagement is organized is getting the
family to come to therapy together. Thus, in engagement, the counselor
assigns tasks that involve doing whatever is needed to get the
family into treatment. For example, a father calls a BSFT counselor
and asks for help with his drug-abusing son. The counselor responds
by suggesting that the father bring his entire family to a session so
that he or she can involve the whole family in fixing the problem.
The father responds that his son would never come to treatment and that he doesn't know what to do. The first task that the counselor
might assign the father is to talk with his wife and involve her in the
effort to bring their son into treatment.
The Task of Coming to Treatment
The simple case. The counselor gives the task of bringing the whole
family into counseling to the family member who calls for help. The
counselor explains why this task is a good idea and promises to support
the family as it works at this task. Occasionally, this is all that is
needed. Often people do not request family counseling simply
because family counseling is not well known, and thus it does not
occur to them to take such action.
Fear, an obstacle that might easily be overcome. Sometimes, family
members are afraid of what will happen in family therapy. Some of
these fears may be real; others may be simply imagined. In some
instances, families just need some reassuring advice to overcome
their fears. Such fears might include, "They are going to gang up on
me," or "Everyone will know what a failure I am." Once these family
members have been helped to overcome their fears, they will be
ready to enter counseling.
Tasks to change how family members act with each other. Very often,
however, simple clarification and reassurance is not sufficient to
mobilize a family. It is at this point that tasks that apply joining, diagnostic, and restructuring strategies are useful in engaging the family.
The counselor needs to prescribe tasks for the family members
who are willing to come to therapy. These need to be tasks that
attempt to change the ways in which family members interact when
discussing coming to therapy. In the process of carrying out these
tasks, the family's resistance will come to light. When that happens,
the counselor will have the diagnostic information needed to get
around the family's patterns of interaction that are maintaining the
symptom of resistance. Once these patterns are changed, the family
will come to therapy.
It should not be a surprise that families fail to accomplish the task of
getting all of their members to counseling. In fact, the therapist's job
is to help the families accomplish tasks that they are not able to
accomplish on their own. As discussed earlier, when assigning any
task, the counselor must expect that the task may not be performed
as requested. This is certainly the case when the family is asked to
perform the task of coming together to counseling.
The application of joining, diagnosing, and restructuring techniques
to the engagement of resistant families is discussed separately below.
However, these techniques are used simultaneously during engagement,
as they are during counseling.
Joining
Joining the resistant family begins with the first contact with the family
member who calls for help and continues throughout the entire relationship
with the family.
With resistant families, the joining techniques described earlier have
to be adapted to match the goal of this phase of therapy. For example,
in tracking the resistant family members to engage them, it is necessary
to track through the caller or initial help seeker and any other
family members who may be involved in the process of bringing
the family to counseling. The counselor tracks by "following" from
the first family member to the next available family member to
the next one and so on. This following, or tracking, is done without
challenging the family patterns of interaction. Rather, tracking is
accomplished by gaining the permission of one family member to
reach the others.
Establishing a Therapeutic Alliance
An effective way for the counselor to establish a therapeutic alliance
they want to solve their problems and that the counselor wants the
same thing. It must be recognized, however, that each family member
may view the problem differently. For example, the mother may want
to get her son to quit using drugs, while the son may want peace at
home.
A therapeutic alliance is built around individual goals that family
members can reach in therapy. Ideally, the counselor and the family
members agree on a goal, and therapy is offered in the framework of
achieving that goal. However, in families in which members are in
conflict over their goals, it is necessary to find something for each of
them to achieve in therapy. For example, the counselor can say to
the mother that therapy can help her son stop using drugs, to the son
that therapy can help him get his mother off his back and stop her
nagging, and to the father that therapy can help stop his being called
in constantly to play the "bad guy." In each case, the counselor can
offer counseling as a means for each family member to achieve his
or her own personal goal.
In engaging resistant families, the counselor initially works with and
through only one or a few family members. Because the entire family
is not initially available, the counselor will need to form a bond with
the person who called for help and any other family members that
make themselves available. However, the focus of this early engagement
phase is strictly to work with these people to bring about the
changes necessary to engage the entire family in counseling. The focus
is not to talk about the problem but rather to talk about getting everyone
to help solve the problem by coming to therapy. By using the
contact person as a vehicle (via tracking) for joining with other members
of the family, the counselor can eventually establish a therapeutic
alliance with each family member and thereby elicit the cooperation
of the entire family in the engagement effort.
Diagnosing the Interactions That Keep the Family From Coming Into Treatment
In engagement, the purpose of diagnosis is to identify those particular
patterns of interaction that permit the resistant behavior to continue.
However, because it isn't possible to observe the entire family, the
BSFT counselor works with limited information to diagnose those
patterns of interaction that are supporting the resistance.
To identify the maladaptive patterns responsible for the resistance,
diagnosis begins prior to therapy, when a family member first calls the
counselor. Because it is not possible to encourage and observe
enactments of family members interacting before they enter counseling,
engagement diagnosis has been modified so that it can be used during
engagement to collect the diagnostic information in other ways.
First, the counselor asks the contact person interpersonal systems questions
that allow him or her to infer what the family's interactional
patterns may be. For example, the counselor may ask, "How do you
ask your husband to come to treatment?" "What happens when you
ask your husband to come to treatment?" "When he gets angry at you
for asking him to come to treatment, what do you do next?" Through
these questions, the counselor tries to identify the interplay between
these spouses that contributes to the resistance. For example, is it
possible that the wife is asking the husband to come to treatment in
an accusatory way, which causes him to get angry? An example might
be, "It is your fault that your son is in trouble because you are sick.
You have to go to treatment."
As was indicated earlier, counselors do not like to rely on what family
members tell them because each family member is very invested in
his or her own viewpoints and probably cannot provide a systemic or
objective account of family functioning. However, when counselors
have access to only one person, they work with the person they
have, strictly for the purpose of engaging that person in treatment.
Second, counselors explore the family system for resistances to the task
of coming to therapy. This is done by assigning exploratory tasks to
uncover resistances that cause the family to fail at the task of coming to
therapy. For example, in the case above, the counselor might suggest
to the wife that she ask her husband to come for her sake and not
because there is anything wrong with him. At that point, the wife may
say to the counselor, "I can't really ask him for my sake because I
know he's too busy to come to the family meetings." This statement
suggests that the wife is not completely committed to getting the husband
to come to treatment. On the one hand, she claims to want him
to come to treatment, but on the other, she gives excuses for why he
cannot. The purpose of exploring the resistance, beginning with the
first phone call, is to identify as early as possible the obstacles that may
prevent the family from coming to therapy, with the aim of intervening
in a way that gets around these obstacles.
Complementarity: Understanding How the Family "Pieces" Fit Together to Create Resistance
What makes this type of early diagnostic work possible is an understanding
of the Principle of Complementarity, which was described in
Chapter 2. As noted earlier, for a family to work as a unit (even maladaptively), the behaviors of each family member must "fit with" the
behaviors of every other family member. Thus, for each action within
the family, there is a complementary action or reaction. For example,
in the case of resistance, the husband doesn't want to come to treatment
(the action), and the wife excuses him for not coming to treatment
(the complementary action). Similarly, a caller tells the counselor that
whenever she says anything to her husband about counseling (the
action), he becomes angry (the complementary reaction). The counselor
needs to know exactly what the wife's contribution is to this circular
transaction, that is, what her part is in maintaining this pattern of
resistance.
Restructuring the Resistance
In the process of engaging resistant families, the counselor initially
sees only one or a few of the family members. It is still possible,
through these individuals, to bring about short-term changes in
interactional patterns that will allow the family to come for therapy.
A variety of change-producing interventions have already been
described in Chapter 4: reframing, reversals, detriangulation, opening
up closed systems, shifting alliances, and task setting. The counselor
can use all of these techniques to overcome the family's resistance to
counseling. In the process of engaging resistant families, task setting is
particularly useful in restructuring.
The next section discusses the types of resistant families that have
been identified, the process of getting the family into counseling, and
the central role that tasks may play in achieving this goal. Much of
counseling work with resistant families has been done with families
in which the parents knew or believed the adolescent was using
drugs and engaging in associated problem behaviors such as truancy,
delinquency, fighting, and breaking curfew. These types of families
are typically difficult to engage in therapy. However, the examples
are not intended to represent all possible types of configurations of
family patterns of interaction that work to resist counseling.
Counselors working with other types of problems and families are
encouraged to review their caseload of difficult-to-engage families
and to carefully diagnose the systemic resistances to therapy. Some
counselors may find that the resistant families they work with are
similar to those described here, and some may find different patterns
of resistance. In any case, counselors will be better equipped to work
with these families if they have some understanding of the more common
types of resistances in families of adolescent drug abusers.
Types of Resistant Families
There are four general types of family patterns of interaction that
emerge repeatedly in work with families of drug-abusing adolescents
who resist engagement to therapy. These four patterns are discussed
below in terms of how the resistant patterns of interaction are manifested,
how they come to the attention of the counselor, and how the
resistance can be restructured to get the family into therapy.
Powerful Identified Patient
The most frequently observed type of family resistance to entering
treatment is characterized by an identified patient who has a powerful
position in the family and whose parents are unable to influence him
or her. This is a problem, particularly in cases that are not courtreferred
and in which the adolescent identified patient is not required
to engage in counseling. Very often, the parent of a powerful identified
patient will admit that he or she is weak or ineffective and will say
that his or her son or daughter flatly refuses to come to counseling.
Counselors can assume that the identified patient resists counseling
for two reasons: It threatens his or her position of power, and counseling
is on the parent's agenda and compliance would strengthen
the parent's power.
As a first step in joining and tracking the rules of the family, the counselor shows respect for and allies with the adolescent. The counselor
contacts the drug-abusing adolescent by phone or in person (perhaps
on his or her own turf, such as after school at the park). The counselor
listens to the powerful adolescent's complaints about his or her
parents and then offers to help the youth change the situation at
home so that the parents will stop harassing him or her. This does
not threaten the adolescent's power within the family and, thus, is
likely to be accepted. The counselor offers respect and concern for
the youth and brings an agenda of change that the adolescent will
share by virtue of the alliance.
To bring these families who resist entering treatment into treatment,
the counselor does not directly challenge the youth's power in the
family. Instead, the counselor accepts and tracks the adolescent's
power. The counselor allies himself or herself with the adolescent so
that he or she may later be in a position to influence the adolescent
to change his or her behavior. Initially, in forming an alliance with
the powerful adolescent, the counselor reframes the need for counseling
in a manner that strengthens the powerful adolescent in a positive
way. This is an example of tracking--using the power of the
adolescent to bring him or her into therapy. The kind of reframing
that is most useful with powerful adolescents is one that transfers the
symptom from the powerful adolescent/identified patient to the family.
For example, the counselor may say, "I want you to come into counseling
to help me change some of the things that are going on in your
family." Later, once the adolescent is in counseling, the counselor will
challenge the adolescent's position of power.
It should be noted that in cases in which powerful adolescents have
less powerful parents, forming the initial alliance with the parents is
likely to be ineffective because the parents are not strong enough to
bring their adolescent into counseling. Their failed attempts to bring
the adolescent into counseling would render the parents even
weaker, and the family would fail to enter counseling. Furthermore,
the youth is likely to perceive the counselor as being the parents' ally,
which would immediately make the adolescent distrust the weak
counselor.
Contact Person Protecting Structure
The second most common type of resistance to entering treatment is
characterized by a parent who protects the family's maladaptive patterns
of interaction. In these families, the person (usually the mother) who
contacts the counselor to request help is also the person who is--
without realizing it--maintaining the resistance in the family. The
way in which the identified patient is maintained in the family is also
the way in which counseling is resisted. The mother, for example,
might give conflicting messages to the counselor, such as, "I want to
take my family to counseling, but my son couldn't come to the session
because he forgot and fell asleep, and my husband has so much
work he doesn't have the time."
The mother is expressing a desire for the counselor's help while protecting
and allying herself with the family's resistance to being
involved in solving the problem. The mother protects this resistance
by agreeing that the excuses for noninvolvement are valid. In other
words, she is supporting the arguments the other family members
are using to maintain the status quo. It is worthwhile to note that
ordinarily this same conflicting message that occurs in the family
maintains the symptomatic structure. In other words, someone complains
about the problem behavior, yet supports the maintenance of the
behaviors that nurture the problem. This pattern is typical of families in
which the caller (e.g., the mother) and the identified patient are
enmeshed.
To bring these families into treatment, the counselor must first form
an alliance with the mother by acknowledging her frustration in
wanting to get help and not getting any cooperation from the other
family members to get it. Through this alliance, the counselor asks
the mother's permission to contact the other family members "even
though they are busy and the counselor recognizes how difficult it is
for them to become involved." With the mother's permission, the
counselor calls the other family members and separates them from
the mother in regard to the issue of coming to counseling. The counselor
develops his or her own relationship with other family members
in discussing the importance of coming to counseling. In doing so,
he or she circumvents the mother's protective behaviors. Once the
family is in counseling, the mother's overprotection of the adolescent's
misbehavior and of the father's uninvolvement (and the adolescent's
and father's eagerness that she continue to protect them) will be addressed because it also may be related to the adolescent's problem behaviors.
Disengaged Parent
These family structures in which one parent protects the family's
maladaptive patterns of behavior are characterized by little or no
cohesiveness and lack of an alliance between the parents or parent
figures as a subsystem. One of the parents, usually the father, refuses
to come into therapy. This is typically a father who has remained
disengaged from the problems at home. The father's disengagement
not only protects him from having to address his adolescent's problems
but also protects him from having to deal with the marital
relationship, which is most likely the more troublesome of the two
relationships he is avoiding. Typically, the mother is over-involved
(enmeshed) with the identified patient and either lacks the skills to
manage the youth or is supporting the identified patient in a covert
fashion.
For example, if the father tries to control the adolescent's behavior,
the mother complains that he is too tough or makes her afraid that
he may become violent.2 The father does not challenge this portrayal
of himself. He is then rendered useless and again distances himself,
re-establishing the disengagement between husband and son and
between husband and wife. In this family, the dimension of resonance
is of foremost importance in planning how to change the family and
bring it into therapy. The counselor must use tasks to bring the
mother closer to the father and distance her from the son. That is, the
boundary between the parents needs to be loosened to bring them
closer together, and the boundary between mother and son needs to
be strengthened to create distance between them.
To engage these families into treatment, the counselor must form an
alliance with the person who called for help (usually the mother).
The counselor then must begin to direct the mother to change her
patterns of interaction with the father to improve their cooperation,
at least temporarily, in bringing the family into treatment. The counselor
should give the mother tasks to do with her husband that pertain
only to getting the family into treatment and taking care of their son's
problems. The counselor should assign tasks in a way that is least
likely to spark the broader marital conflict. To set up the task, the
counselor may ask the mother what she believes is the real reason
her husband does not want to come to counseling. Once this reason
is ascertained, the counselor coaches the mother to present the issue
of coming to treatment in a way that the husband can accept. For
example, if he doesn't want to come because he has given up on his
son, she may be coached to suggest to him that coming to treatment
will help her cope with the situation.
Although the pattern of resistance is similar to that of the contact person
protecting the structure, in this instance, the resistance emerges
differently. In this case, the mother does not excuse the father's distance.
To the contrary, she complains about her spouse's disinterest;
this mother is usually eager to do something to involve her husband;
she just needs some direction to be able to do it.
Families With Secrets
ometimes counseling is threatening to one or more individuals in
the family. Sometimes the person who resists coming to counseling
is either afraid of being made a scapegoat or afraid that dangerous
secrets (e.g., infidelity) will be revealed. These individuals' beliefs or
frames about counseling are usually an extension of the frame within
which the family is functioning. That is, it is a family of secrets.
The counselor must reframe the idea or goal of counseling in a way
that eliminates its potential negative consequences and replaces them
with positive aims. One example of how to do this is to meet with
the person who rejects counseling the most and assure him or her
that counseling does not have to go where he or she does not want
it to go. The counselor needs to make it clear that he or she will
make every effort to focus on the adolescent's problems instead of
the issues that might concern the unwilling family member. The
counselor also should assure this individual that in the counseling
session, "We will deal only with those issues that you want to deal
with. You'll be the boss. I am here only to help you to the extent that
you say."
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